Patients with coronary artery disease who are anxious are at significantly greater risk for myocardial infarction and death than peers who are not anxious, according to an article in the May 22 issue of the Journal of the American College of Cardiology.

Previous studies have shown that mental stress and depression have harmful effects on the heart and blood vessels, but until now there has been little information on the possible negative effects of anxiety or the benefits of relieving anxiety over time.

For the study, Charles M. Blatt, MD, of Harvard Medical School, Boston, Massachusetts, and his colleagues recruited 516 patients with proven coronary artery disease. At the beginning of the study and again each year patients completed a standardized questionnaire about their feelings during the previous week, for example, whether they felt peaceful, felt something bad would happen, took a long time to fall asleep at night, or had upset bowels or stomach.

Patients were followed for an average of more than three years. During that time, 19 patients died and 44 had a nonfatal myocardial infarction. Cumulative anxiety scores were averaged and adjusted for age, and the patients were divided into three groups. Those with anxiety scores in the highest third had nearly double the risk of myocardial infarction or death compared with peers with anxiety scores in the lowest third (hazard ratio, 1.97). The data showed that there was a 6-percent increase in risk of death or myocardial infarction each time the average cumulative anxiety scored rose by 1 unit.

The initial anxiety score alone offered little clue to the patient’s future health. However, an increase in anxiety over time increased the risk of myocardial infarction or death by 10 percent. Conversely, patients whose anxiety level was in the highest third at baseline, but in the lowest third when cumulative average anxiety levels were tallied, were among the least likely to have an infarction or to die.

This finding shows not only the need for repeated measurements to accurately gauge the impact of anxiety but also suggests an important role for physicians in reassuring anxious patients, Blatt said. Spending extra time with patients and families gives the cardiologist an opportunity to talk about heart disease, adjust medications, encourage exercise, and come up with effective strategies to improve cardiac risk factors, such as smoking, high cholesterol and high blood pressure. Equally important, it helps to establish a caring relationship that allays the fears that could shorten a patient’s life.

“I tell patients well-managed coronary disease is consistent with a long happy life. If you give people this type of reassurance, it turns a frightening disease into something they can grow old with,” Blatt said.

James L. Januzzi, MD, agreed. “This study provides further insight into the complex connections between the brain and heart,” said Dr. Januzzi, an associate professor of medicine at Harvard Medical School and director of the cardiac intensive care unit at Massachusetts General Hospital, Boston. “Appropriately, cardiologists have traditionally focused their therapeutic efforts on factors known to influence long-term outcome in coronary disease, such as making sure to aggressively lower LDL cholesterol. The results of this study demonstrate that we may need to consider more thoroughly evaluating patients with mood disorders such as anxiety, as treatment may very well reduce the risk of heart disease.”